Innovation often happens at a faster pace than rules governing the delivery model are established, and mobile integrated healthcare (MIH) has been no exception. During a presentation at the November 2015 American Ambulance Association conference, noted EMS legal expert and JEMS editorial board member Doug Wolfberg, JD, EMT, stated that many states don’t have specific legislation supporting or prohibiting the delivery of MIH and community paramedicine (MIH-CP).
Further, because the published reports about MIH programs across the country demonstrate the inherent benefit to the patients in the programs, he commented that some providers are using the tried and true philosophy, “sometimes it’s easier to seek forgiveness than to gain permission.”
Some states—usually at the behest of tenacious EMS providers— have passed legislation specifically supporting MIH-CP program development. Following is a summary of legislation enacted in the past three years that specifically relates to MIH-CP.
Arkansas: House Bill 1133 Act 685 was enacted this year. The law creates a program for licensure of community paramedics and allows community paramedics to provide services as directed by a patient care plan after the plan has been developed, approved, or both by the patient’s physician in conjunction with the community paramedic’s agency’s medical director.
Idaho: House Bill 153 was enacted in 2015. It defines “community health EMS” as the evaluation, advice or treatment of an eligible recipient outside of a hospital setting, which is specifically requested for the purpose of preventing or improving a particular medical condition, and which is provided by a licensed EMS agency. It also defines a “community emergency medical technician” and an EMT or advanced EMT with additional standardized training who works within a designated community health EMS program under local medical control as part of a community-based team of health and social services providers.
Maine: Public Law Chapter 562 was enacted in 2012. It allows the Maine EMS Board to authorize up to 12 pilot projects throughout the state. Working under the supervision of a primary care provider, community paramedics can work with chronically ill patients who are at risk for hospital readmission. Community paramedics can also do follow-up care for patients referred by healthcare providers including vital sign checks, clinical evaluations, assure medication compliance and conduct treatments. The law also requires the EMS Board to submit a written report to the legislature that summarizes the work and progress for each authorized pilot.
Massachusetts: House Bill 3650 was enacted in 2015 and becomes effective Dec. 31, 2015. It requires the Massachusetts Department of Public Health to evaluate and approve “community EMS programs” and other MIH programs developed and operated by the primary ambulance service with the approval of the local jurisdiction and the affiliate hospital medical director. These programs can provide community outreach and assistance to residents of the local jurisdiction in order to advance injury and illness prevention within the community. The law also establishes a statewide MIH advisory council.
Minnesota: Senate File 0119 Session Law Chapter 12 was enacted in 2011. It defines EMT-community paramedics (EMT-CP) and establishes a process for certification. It also establishes training and clinical requirements for certification, including completion of a community paramedic training program from an approved college or university, and authorizes community paramedics to provide services as directed by the patient’s primary care physician. It also enables community paramedics to provide specific health services, as well as prevention, emergency care, evaluation, disease management and referrals. A subsequent Bill, Senate 1543, enacted in 2012, authorizes medical assistance (Medicaid) reimbursement rates as determined by the Human Services Commission to cover community paramedic services to certain high-risk individuals, including frequent ED users or other patients who have been identified as at-risk for hospital readmission.
Missouri: House Bill 653 was enacted in 2013. It authorizes paramedics who receive additional education and certification to serve as community paramedics—working under a medical director—to provide healthcare services to populations with limited access to primary care services. It specifies that a community paramedic shall practice in accordance with protocols and supervisory standards established by the medical director and shall provide services of a healthcare plan if the plan has been developed by the patient’s primary physician or by an advanced practice registered nurse or a physician assistant and there’s no duplication of services to the patient from another provider.
Nevada: Assembly Bill 305 was enacted in 2015. It creates a definition of community paramedicine services that are provided by an EMT, advanced EMT or paramedic to patients who don’t require transportation to or services at a hospital and provided using mobile equipment in a manner that’s integrated with the healthcare and social services resources available in the community. It goes on to state that such services may include, without limitation, transportation to a facility other than a hospital, which may include a mental health facility, and the provision of healthcare services provided to patients on a scheduled basis.
Ohio: House Bill 64 was enacted in 2015. Section 4765.361 allows EMTs and paramedics employed by public agencies to work on patients in nonemergency situations. The law also states that in nonemergency situations, no medical director or cooperating physician advisory board shall delegate, instruct or otherwise authorize a technician to perform any medical service that the technician isn’t authorized by law to perform. Due to a unique governance board arrangement, this law only applies to publicly employed EMTs and paramedics. Private providers are governed by a different set of rules and laws.
Tennessee: Senate Bill 2029 was enacted in 2014. It did two things for EMS personnel: 1) It allows them to provide non-emergent patient care; and 2) Prohibits them from functioning as home care organizations. As enacted, it revises duties and the authority of EMS personnel in regard to the provision of certain care and treatment, including in nonemergency settings. The previous law only allowed personnel to function in an “emergency” setting while still specifying that providers aren’t authorized to function as a home care organization.
Washington: Senate Bill 5591 Chapter 93 was enacted in 2015. It authorizes EMS providers that levy an EMS tax and federally recognized Indian tribes to establish community assistance referral and education services programs. It also allows EMTs, advanced EMTs and paramedics to provide care in nonemergency and non-life-threatening situations if they’re participating in a program and the care provided doesn’t exceed their training and certification standards.